Peak Flow Meter Usage Technique Review With Informed Consent Form

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Title: Peak Flow Meter Usage Technique Review .
Patient details
Ref number:
Date of review:
GP, pharmacist, practice nurse or clinical specialist observes the patient completing the following
steps and scores 1 (satisfactory) or 0 (not satisfactory) depending on whether the step is
completed satisfactorily
Where a separate mouthpiece is required, attach mouthpiece to Peak
Flow Meter. (Mouthpiece may be disposable). If no ‘mouthpiece’ is
required, reviewer adds 1 point to score.)
Ensure that the cursor is back to base/zero and that the fingers do not
block movement of the cursor.
Hold Peak Flow Meter level/horizontal, while the patient sits/stands as
straight as possible
… take a steady, deep breath in and hold breath while…
… putting mouthpiece in mouth between the teeth and close lips around
the mouthpiece…
… and blow a hard fast breath out through the mouthpiece (NOT nose)
Measure where the cursor stops …
Repeat steps 2 to 7 twice.
Record the highest of the three results as the Peak Flow Reading (onto a
Peak Flow Chart.) Explain interpretation of results and action steps, if
Where a separate disposable mouthpiece is required,
dispose of the disposable mouthpiece.
Signed/initialled by pharmacist/professional staff:
Date of assessment:
Recording of Patient Informed Consent:
a) Patient’s reason for choosing to attend for Peak Flow meter Technique Review:
b) I have received information about the Peak Flow Meter technique review process and give my consent __________:
I agree that information may be shared with my GP or carer (specify) ___________________ Date: ____________
d) I consent to the use of Peak Flow Meter Technique Review results, my name/identification having been removed,
being used for audit purposes, including the accumulation of such data for research purposes.
Patient signature:
Prepared by: Rachel Dungan MPSI, Cicely Roche MPSI on behalf of the Asthma Society of Ireland and Irish Pharmacy Union
Date: 18/8/15
Ver: 05


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Parent category: Medical